29 March 2012 3:03 PM

Breast implants: an ethical and practical minefield

Women have breast implants because they want to feel better about their appearance. As a man, I have no right to an opinion on this subject. However, as a former GP, I do have some observations.

My guess is that, as for cosmetic surgery of any kind and as for clothes and hairstyles, women judge themselves by what other women will think of their looks. Male opinions are a secondary consideration.

So, women may possibly have breast implants because of their own perceptions and personal values, rather than because of anything specifically to do with their breasts.

Some women have lopsided breasts or may be flat chested. Cosmetic surgery for them is a relatively straightforward consideration. The physical state is presumed to lead to a psychological state of distress.

Other women have had cancer, or other diseases of one or both breasts, and may understandably want to look as near as possible to what they were like before they had surgery. Again, the psychological considerations are relatively straightforward, as are the physical options.

It is only when implant operations are done for purely psychological reasons, in the absence of significant physical impairment that would be obvious to anyone other than the patient, that challenging ethical issues arise.

But should there be a problem even then? Maybe women should have a right to cosmetic surgery on demand. There are two difficulties with that attitude.

Firstly, body dysmorphia is the clinical condition in which women, commonly those with eating disorders, do not perceive their own form as other people see it. Some women become addicted to cosmetic surgery in their quest to find the perfect shape. They would probably benefit more from psychological treatment than surgical intervention.

Secondly, there is the issue of what surgical procedures should reasonably be provided from within the inevitably limited resources of the NHS. To provide every possible treatment for every possible physical and psychological condition would require more resources than the gross national product of our country. Rationing, in some form, is inevitable. It is also necessary so that those in greatest need of help are most likely to receive it.

This is where the financial and ethical dilemmas arise.

Let's start with an easy case. If a woman has cancer of the breast, it would normally be taken for granted that the State would pay for treatment. If an implant is inserted after her surgery, it would generally be thought reasonable for the State to pay for that. Maybe in extreme old age there could be a question on whether the potential risks of an implant were worth the benefits when a comfortable external prosthesis might be acceptable to the patient. Ageism is not a clear-cut concept.

But supposing the woman had paid for her cancer surgery and implant privately. If the implant then had to be replaced, would it be reasonable for her to have that done under the NHS, if she is entitled to it, or should she go back to the private surgeon?

Now consider the issue of an operation done for purely cosmetic reasons. If the initial operation was done in the NHS, after due consideration of psychological factors, then it would be reasonable to expect a faulty implant to be replaced under the NHS. If there is a long delay before hard-pressed NHS services are available and if there are dangers in not having the implant replaced, it would be reasonable for the procedure to be done privately and for the NHS to pay the bill.

But now look at the issue of an implant operation that was done in the private sector for purely cosmetic reasons. The woman herself would say that there was psychological justification. But an NHS psychologist might have said that the physical issue, and hence the psychological consideration, would not have been sufficient justification for surgery under the NHS.

Supposing this woman had spent all her savings on the original implant and now had no money to pay for the more complex surgery involved in the removal of a faulty implant and replacement by a new one. Should that procedure be done under the NHS if the woman is entitled to NHS care? Or should the private surgeon and hospital foot the bill?

Would the situation be any different if the patient is wealthy but still entitled to NHS care?

This brings up the whole issue of the relationship between the state and private sectors in health care.

These considerations are thorny at the best of times. In the present circumstance, it is likely that everyone will have an opinion and nobody will listen to any other,

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DR ROBERT LEFEVER

Dr Robert Lefever established the very first addiction treatment centre in the UK that offered rehabilitation to eating disorder patients, as well as to those with alcohol or drug problems. He was also the first to treat compulsive gambling, nicotine addiction and workaholism.
He identified 'Compulsive Helping', when people do too much for others and too little for themselves, as an addictive behaviour and he pioneered its treatment.
He has worked with over 5,000 addicts and their families in the last 25 years and, until recently, ran a busy private medical practice in South Kensington.
He has written twenty six books on various aspects of depressive illness and addictive behaviour.
He now provides intensive private one-to-one care for individuals and their families.

He has written twenty six books on various aspects of depressive illness and addictive behaviour.

He now uses his considerable experience to provide intensive private one-to-one care for individuals and their families.